The
following interview with Medical Director William
Kettyle
[WK] was conducted by the Faculty
Newsletter [FNL] on August 6th of
this year.

FNL: Let's start with a little
background info, and how you wound up here at the
Institute.

WK: I've been in practice in
Cambridge for about 25 years. For the first 15 I was at Mt. Auburn
Hospital, practicing internal medicine and endocrinology. About 10
years ago I came to the MIT Medical Department. I have had a long
relationship with MIT via the HST Program where I've taught endocrine
pathophysiology for 20-plus years. I had a long-term chronic job
offer from the Medical Department and I finally took them up on the
offer to come here. Although I came as a clinician, I've gradually
become more involved in administrative matters. For the last three
years I have been the medical director. My interests are in patient
care and in teaching people how to take care of patients. I continue
to teach in the HST program. Although I continue to see patients and
to teach, much of my time is now spent on things
administrative.

FNL: How many people do you
administer? What's the staff?

WK: There are approximately
280 employees and about 100 contractors who work in the Medical
Department.

FNL: Health services at the
Institute, we believe, are viewed by many faculty and staff as one of
the most, if not the most, important quality of life resource. And
the consensus of concern seems to be the possibility of the Institute
outsourcing health services . . . especially given the budgetary
difficulties Institute-wide. What do you see as the broad picture for
the future of health services here?

WK: Over the years we've tried
to accommodate to the changes that have occurred at the Institute
and, at the same time, to accommodate to the changes that have
occurred in the medical world around us. The vast majority of care
needs can be met here at our facilities. And if we can't meet the
need, we try to facilitate the best care in the community around us.
So it's important that we maintain good relationships with
surrounding medical resources to back up our operation here.

The financial constraints that the
Institute is under will have an impact, and are having an impact.
They are requiring us to look carefully at the services we offer, so
that we're focused on the services that the Institute needs. We need
to be sure that we're using our resources as efficiently as we can so
that we can maintain the availability of one-site, low-barrier,
high-quality care.

FNL: Were you given a specific
percentage for budget reduction that all of medical has to take?

WK: We were given a budgetary
reduction target. The percentage was seven percent for FY04. A major
question is seven percent of what number? A large amount of money
goes through us and not to us. Money, largely Health Plan premiums,
goes through us to pay bills for hospital and other services provided
outside the Medical Department. The seven percent reduction was made
on an expense base of approximately $28,000,000 and amounts to about
$2,000,000. In addition,for a number of years the Medical Department
has been over spending its budget and dipping into reserve funds. A
significant part of our budget-related actions were to further
decrease our spending in order to stay on budget. Over half of our
expense budget is balanced with income from Health Plan premiums and
fees for service. Approximately $12 million a year, or something of
that magnitude, comes from the Institute to support the care of
students, job site-related care, and community health activities.
With about 10,000 students, we estimate that the cost for the care of
students is about $1000 per student per year.

FNL: Do the students pay that,
or does the Institute?

WK: Many schools charge a
"Health Fee" to students. At MIT the cost of student health care is
imbedded in the tuition.

FNL: So it's all rolled into
the tuition, including the graduate tuition.

WK: Right. Supplemental
insurance costs are not covered by tuition. This coverage pays for
care that cannot be provided at the Medical Department. The cost of
this supplemental coverage has gone up dramatically which places
increased financial pressure on our students.

FNL: There's been a lot of
concern about popular, well-respected doctors leaving the Institute.
Lori Wroble in gynecology and Eric Schwartz in dermatology, to name
two. So the questions are: are you replacing people, and why do you
think they're leaving? Does it have anything to do with a tightening
of resources or more work because of budget cuts?

WK: I think many of the
personnel changes are the result of changes in personal life
circumstances. For example, Dr. Schwartz moved to California and is
now married. Other changes have been, for the most part, because of
personal issues, lifestyle changes, moves, or something along those
lines. However, I think I'd be less than frank if I didn't say that
Lori Wroble's departure was in part related to the decrease in
resource availability. We have and will maintain on-site services in
dermatology and in obstetrics and gynecology. We are in the midst of
working out ways of dealing with these issues. We are forging
partnerships or recruiting to maintain these important services. Many
of our clinicians have been here for many years, and our turnover
rate is relatively low. Although that doesn't help make the person
who has just lost their dermatologist or their gynecologist feel any
better, but compared to other medical practices, our turnover rate is
relatively low.

FNL: It seems that women
faculty members are most concerned about the health care situation at
the Institute, with the desire for more women doctors, for example.
One would assume that's an issue aside from any financial question,
although they are connected. What with the increase of women at the
Institute and that traditionally more doctors were men . . .do you
see that at all  the direct need to hire more women?

WK: Absolutely. And one of the
issues that we're trying to address now is finding the best way to
meet the health needs of women in our community. We had a very
interesting meeting with representatives of the women faculty. The
meeting was sparked largely by the changes that are occurring in the
Obstetrics and Gynecology Service. The changes are fiscally driven at
some level, but at another level it's, I think, a process of making
sure that we are using our resources in a way that best serves this
community. In the OB/GYN area it is largely an issue of scale. The
birth rate has been relatively stable and relatively low and the
fixed costs of taking care of a relatively small number of deliveries
are great. And what we need, I think, is to forge a partnership with
a group that can spread out some of the fixed costs of coverage. The
goal is to continue to have on-site obstetric services and to also
have the staffing to meet the GYN needs of our community. During the
discussion with members of the women faculty it also became very
clear that there was an important need for enhancement of primary
care services for women in our community. We are in the process of
thinking together with the women in our community, among ourselves
here and with colleagues in the medical community around us, about
designing a system that would meet the health care needs of women.
Delivering babies is clearly important, but it is one part of the
care need. Rebalancing our spending on obstetrics will allow us to
redirect resources in a way which I think will enhance the care of
women in the MIT community.

FNL: I don't believe there's
been a permanent replacement for Dr. Schwartz yet.

WK: We have not been able to
find a permanent replacement.

FNL: So it's not for lack of
looking.

WK: It is not for lack of
looking.

FNL: So why do you think that
is? And have there been other people in areas other than dermatology
who have come in recent years? And if not, why not? And what can one
do to make it more attractive?

WK: We have several new
clinicians who have joined us over the last several years. Some join
our department as contractors, as opposed to employees. We've been
shifting away from hiring very part-time employees. When the care
needs require the services of a very part-time clinician (less that
50 percent) we try to meet the clinical need with a clinician who
provides services as a contractor - paid for time worked, without
benefits. We can often control costs and provide service in a more
plastic way by use of contractors. When the need supports more time,
greater than 50 percent, regular employment is the preferred
route.

FNL: And we don't have those
people now? Or are you trying to get more people in?

WK: We have about 150 employed
clinicians and about 100 contractors who provide services here at MIT
Medical.

FNL: Are those cheaper?

WK: Contractors may be less
expensive  largely because we don't have to pay benefits for
them. The hourly rate or the contractual rate is, in large measure,
market driven. Our commitment to them and theirs to us is relatively
less than an employee. In spite of this we have had many very
long-term contractual relationships with some of our clinicians.

FNL: That 50 percent figure is
important.

WK: Exactly. You need 50
percent effort to become benefits eligible. Retaining good people is
something that we're very concerned about and want to be sure that
we're making this a comfortable place to work. Workplace environment
(an area highlighted in our strategic planning process) has been an
important focus of several activities in the last couple of years.
With regard to dermatology, the competition in the outside world is
significant. Many dermatologists can make very large amounts of money
doing cosmetic things like tucks, laser treatments, and this and
that. The competition is great for skilled dermatologists.

FNL: So that particular one
you're going to replace. But in pediatrics, for example, my
understanding is that people have left and that they're not going to
be replaced.

WK: The issues in the
Pediatrics Service are also issues of scale. The number of children
served in the population is relatively small and we felt, as we
reviewed things, that we had the capacity to care for our population
of children with a slightly reduced force of pediatricians.

FNL: So the flip side of that
point is what about gerontologists? Have we got one?

WK: We have one. You're
looking at him.

FNL: You're the gerontologist.
Do we need another one?

WK: [LAUGHTER] Most of
our internists are very comfortable with the geriatric age group. But
there is only one of us who is board certified in
geriatrics.

FNL: There has been a lot of
discussion the last several years about people who would love to
teach at MIT but don't feel they can afford to - the cost of living,
the necessity of living further away from campus, what about their
kids. Have you found anything like that in the hiring, that people
are hesitant to relocate around here?

WK: The Massachusetts Medical
Society provides information that suggests that Boston, and
Massachusetts in general, are less desirable places for physicians to
work, because of salaries, because of cost of living, because of some
issues of job satisfaction, malpractice costs, etcetera. In spite of
this, I don't think that it has been a huge factor in our hiring.

FNL: Have you hired mid-career
positions or have they been more at the entry level?

WK: We have hired more in the
mid-career level than at entry level.

FNL: Do you feel you're able
to fill the need with the contractors  for example, in
dermatology? Someone could make an appointment to see a dermatologist
here. You're not going to send a patient to a private physician
somewhere else, are you?

WK: Patient care is obviously
the most important thing. To the extent that we can provide the
services here, we will make every effort to do that. But when we do
have staff deficiencies, we will try to make them up in the
community.

FNL: Prospective graduate
students and undergraduates are often told when they apply that the
medical department is a real resource that other places don't have.
From your perspective, would you say that's an accurate statement?

WK: Yes, I think so. I think
we have a breadth and depth of services on campus that is at the top
of the heap of comparable institutions. Harvard, Yale, and Stanford
are the places we compare ourselves to most frequently. In addition
to caring for students these universities also have an HMO or provide
medical services for faculty and staff and their families.

FNL: Do those other places
have a hospital or infirmary, as we do?

WK: Harvard has an infirmary.
Yale has an infirmary. Stanford uses the Stanford Hospital.

FNL: Stanford's is right on
campus, though. Let's tie this into the gerontology question. The
infirmary seems to be an incredibly important facility for retired
and older faculty. But it's something I would think that's
particularly vulnerable.

WK: The infirmary is a
wonderful resource. It's a place where any one of a number of
different types of care can be provided. End-of-life services can be
very nicely done there. Immediate post-operative recovery after an
operation we can do very comfortably there. We also serve the care
requirements of students who may be living in a dormitory or
independent living group. For example, a student with mononucleosis,
if he or she lived nearby, could go home for a few days and get care.
If they live in Cleveland or if they live in Karachi, they can't go
home so easily  we can provide the care here.

The Inpatient unit provides a range
of very valuable services for our community. The use of the inpatient
unit, however, is at a level that makes the cost per case relatively
high. This is a function of the fixed costs of running the facility
and a relatively small volume of people using it. Is it the best use
of our resources? I think it is a good use of resources. In my view
the care benefits trump the cost, but we clearly need to be sure we
are using this resource as effectively as we can. One possibility is
to decrease the size of the Inpatient Unit to the size that will just
meet the needs of students and a few post-operative patients. When we
analyze that option we find that the gain is mostly in space and very
little in dollars because of the relatively high fixed costs of 24/7
staffing around the year. Another option is to think about whether we
could use the facility for patients from other educational
institutions. On the one hand that has a lot of charm; on the other
hand we don't want to dilute our commitment to this community. The
Inpatient Unit is an expensive resource but it's a wonderful
resource, a valuable resource.

FNL: Do you view this facility
in any way being in danger of being outsourced by the institution or
severely cut back in some way, or can the faculty be at least
somewhat comforted by the thought that the director would say that
this is a resource that all the highest levels of the Institute
people appreciate, and is likely to be preserved for the indefinite
future?

WK: I think that we will
endure for the indefinite future. We play an important role in the
life and care of the Institute. But I don't think that this immunizes
us from the need to responsibly use our resources. We need to be sure
that our costs are realistic and that our services meet the needs or
our community.

FNL: So do you anticipate the
rate going up for the MIT Plan or the Flexible MIT Plan?

WK: Rate increases are in
many, many ways a function of our outside costs, of costs that we
don't have a whole lot of control over. Because we are buying many of
the services we need for our community in the same medical community
in which Blue Cross and the Tufts Health Plan are doing business, we
are faced with similar costs for hospital services. The other large
driver is the increasing cost of pharmaceuticals. Unfortunately,
there will be an increase in our rates. We are working hard to keep
that increase as small as possible. Success at some level is a
smaller increase. No increase is unrealistic.

FNL: What about the Lincoln
Laboratory Medical Center? It's beautiful, but is it cost effective?
Are you the director there as well?

WK: Yes I am.

FNL: What fraction of the 280
employees are out there as opposed to here?

WK: There are about 15
clinicians and support staff who spend time at the Lexington
facility. Some of these are there for only one session a week or
less. There are four to six staff members there on a daily basis.
We've always provided on-site job-related care at Lincoln Lab, and so
with the opening of this center three years ago, we augmented the
services available there. Our hope was that it would build the
Health
Plan membership. And we have
seen some growth in Lincoln Lab-related Health Plan membership. But
the volume there is relatively low. And from simply an economic point
of view, it's not very cost effective. From a care point of view,
from a community point of view, and from the point of view of our
important relationship with Lincoln Laboratory, it has been very
successful, but at a high cost.

FNL: What about the changes in
psychiatric care? That's been in the news for the last couple of
years, the increase in psychiatric attention to the students
primarily.

WK: The use of mental health
services by students has increased significantly both here and across
the country over the last several years. The need for psychiatric
care is quite clear and was underscored by the report of the Mental
Health Task Force. Their report pointed out a need for more outreach,
and called for more easily available mental health services. We have
been working hard to try to respond to their suggestions and to meet
the mental health needs of our community. We have increased our
mental health staff by about four people over the last year,
increasing our outreach efforts, and increasing our hours of
availability for mental health services.

FNL: But isn't it all one pie,
so if you increase that by four, aren't there four other medical
people that cannot get a chance to be hired?

WK: We requested additional
fiscal support and with a salary supplemental were able to increase
the Mental Health staff. So the pie has indeed gotten a little
bigger.

FNL: What about the increase
in the pharmaceutical co-payment? Is that supporting anything else
besides the drugs?

WK: We have a three-tier
pharmacy formulary system. These arrangements are designed to nudge
patients and clinicians toward lower cost options for drugs. Brand
name and heavily marketed drugs are available, but usually at a
higher cost to the patient. Our three-tier formulary system is not at
all a revenue generating endeavor. It has, however, effectively
helped us contain the rapidly rising costs of pharmaceuticals for our
Health Plan and for our patients.

FNL: Is there anything else
you'd like to add before we close?

WK: We want to preserve the
services and the on-site availability that we provide on this campus
 for students, for faculty, for staff, for everyone who is a
member of the MIT community. We need resources to do this. Our
resources come from well-run and cost effective health plans and from
the support of the Institute for the care of students, employees, and
for community health activities. In addition to needing adequate
resources we must be sure that we are deploying them in responsible,
cost effective ways that meet the needs of our community. We want to
focus our efforts and resources where they are most needed and can be
most effective. We are both part of and insulated from the medical
community around us. Medical costs are rising relentlessly. The
challenges are significant and the need for focus and continued
monitoring of the needs of our community is great.

I realize that some of the changes
that are happening and that we are making are having a significant
effect on many members of our community. Changing clinicians and
changing jobs is never easy. We are trying to keep the changes to a
minimum and the service to our community at a maximum.